2 - Comparison of Supervised Exercise With

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Journal of Orthopaedic Sports Physical Therapy

2000;30 3):126-137

Comparison of Supervised Exercise With

and Without ~ a n u a l hysical Therapy for

Patients With Shoulder Impingement

Syndrome

Mi c h a e l

D. ang PT1

Ga i l D . D e y le

MP7;

CS2

Study

Design:

A

prospective randomized clinical trial.

Objective: To compare the effectiveness of 2 physical therapy treatment approaches for

impingement syndrome of the shoulder.

Background: Manual physical therapy combined with exercise is a commonly applied but

currently unproven clinica l treatment for impingement syndrome of the shoulder.

Methods and Measures: Thirty men and 22 women age 43 years 9.1) diagnosed with

shoulder impingement syndrome were randomly assigned to of 2 treatment groups. The

exercise group performed supervised flexibil ity and strengthening exercises. The manual

therapy group performed the same program and received manual physical therapy

treatment. Both groups received the selected intervention

6

times over a 3-week period. The

testers, who were blinded to group assignment, measured strength, pain, and function before

treatment and after 6 physical therapy visits. Strength was a composite score of isometric

strength tests for internal rotation, external rotation, and abduction. Pain was a composite

score of visual analog scale measures during resisted break tests, active abduction, and

functional activities. Function was measured with a functional assessment questionnaire. The

visual analog scale used to measure pain with functional activities and the functional

assessment questionnaire were also measured 2 months after the initia tion of treatment.

Results:

Subjects in both groups experienced significant decreases in pain and increases in

function, but there was significantly more improvement in the manual therapy group

compared to the exercise group. For example, pain in the manual therapy group was

reduced from a pretreatment mean 2SD)of 575.8 2220.0) o a posttreatment mean of

174.4 2183.1). In contrast, pain in the exercise group was reduced from a pretreatment

mean of 557.1 2237.2) o a posttreatment mean of 360.6 2272.3). Strength in the manual

therapy group improved significantly while strength in the exercise group did not.

Conclusion: Manual physical therapy applied by experienced physical therapists combined

with supervised exercise in a brief c linical tr ial is better than exercise alone for increasing

strength, decreasing pain, and improving function in patients with shoulder impingement

syndrome.

/

Orthop

Sports

Phys

Ther

2000;30:126 137.

Key

Words:

exercise manua l physical therapy shoulder impingement syndrome

Coordinator Primary Care Physical Therapy Department of Medicine Kaiser Permanente Medical

Center Vallejo Calif.

Colonel and chief of physical therapy Brmke Army Medical Center Fort Sam Houston Tex.

This study was funded in part by grant 114-9720 from the Kaiser Foundation Research Institute in

northern California.

Send correspondence to Michael D Bang Department of Medicine Kaiser Permanente Medical

Center 975 Sereno Drive Vallejo C 94590. E-mail: [email protected]

S

oulder disorders are

among the most com-

mon of all peripheral

joint ~omplaints.~. he

cumulative incidence of

shoulder problems in general

medical practice is estimated to be

1 .2/ 1000 patients per yea 5

Shoulder impingement syndrome

and rotator cuff tendinitis are con-

sidered to

be

the most frequent

cause of intrinsic shoulder pain

and d i ~ a b i l i t y . ~ ~ . ~ , ~mpingement

in the shoulder occurs when the

soft tissues occupying the sub-

acromial space are encroached

upon by the coracoacromial

arch.44Outcome studies7 reveal

that these disorders are not neces-

sarily self-limiting. Disorders in-

volving shoulder impingement are

often refractory to nonsurgical

treatment including conventional

physical therapy, and can result in

chronic symptoms with functional

impairment.7*Hhoulder impinge-

ment disorders are currently classi-

fied as either primary or second-

ary.17.1%.Jl

Cumulative microtrauma sus-

tained by the subacromial tissues

during overuse and repetitive sub-

acromial loading is the theorized

cause of primary impinge-


2/12

ment.25.J'.4Vntrinsic egenerative tendinopathies of

the rotator cuff and anatomic variations of the acro-

mion process are thought to increase the vulnerabili-

ty of this region to impingement.41.47.54osterior ca p

sule tightness and weakness of the shoulder rotator

musculature have been reported in patients with pri-

mary shoulder

Secondary impingement is reported in athletes

who participate in sports that require frequent over-

head a~tivity.'~.'~he etiology of secondary impinge-

ment is considered to be subtle glenohumeral insta-

bility or hypermobility. It has been proposed that

such instability combined with inadequate recruit-

ment of the active stabilizers of the glenohumeral or

scapulothoracic oint, results in excessive anterior

and superior migration of the humeral head. Exces-

sive displacement of the humeral head in turn en-

croaches on the soft tissues lying within the suba-

cromial s p a ~ e . ' ~ : ~ ~ ~ ~ ' ~ ~ ~ommon clinical findings as

sociated with secondary shoulder impingement are

excessive range of motion (ROM) into external rota-

tion, weakness of the internal rotators, and de-

creased endurance ratios of the shoulder abductors

and external rotator^ ^ ^

It has been determined that 15-28% of patients di-

agnosed with shoulder impingement syndrome may

eventually require s ~r g er y .~ .~ 'ommonly prescribed

treatments for shoulder impingement include non-

steroidal anti-inflammatory medications, thermal mo-

dalities, and subacromial corticosteroid injec-

t i o n ~ . ~ ~ ~ . ~ ~ .herapeutic exercise regimes are also ad-

vocated to restore shoulder mobility and stability, by

improving ROM and enhancing glenohumeral as

well as scapulothoracic muscle f u n c t i ~ n . ~ ~ . . ~ ~ . ~ ~ . ~

Brox et alwetermined in a randomized controlled

clinical trial that exercise supervised by a physical

therapist was superior to placebo and was as effective

as surgical subacromial decompression combined

with postoperative rehabilitation in the treatment of

patients with stage I1 primary impingement. recent

randomized, controlled studyIw eported improved

ROM, decreased pain, and increased function in pa-

tients with shoulder pain. These patients received an

individualized physical therapy program consisting of

muscle stretching, strengthening, and retraining.

Physical therapists have advocated the use of pas-

sive joint mobilization, soft tissue mobilization, and

muscle stretching as an effective means of treating

shoulder d y s f u n c t i ~ n . ' ~ ~ ~ ~assive joint mobilization

is considered to be an effective treatment for en-

hancing ROM in the patient with shoulder impinge-

ment.J 4h Nicholson49eported significant improve-

ment with passive shoulder abduction in patients

with adhesive capsulitis who received joint mobiliza-

tion combined with active exercise.

The influence of thoracic spine mobility and curva-

ture on shoulder ROM and scapular position;' J1 the

prevalence of significant forward head posture in s u b

T BLE 1

Inclusion criteria.

Category I: impingement signst

1.

Passive overpressure at full shoulder flexion with the scapula stabi-

lized.

2. Pdssive internal rotation at

90

shoulder flexion in the scapular plane

and in progressive degrees of horizontal adduction.

Category

II:

active shoulder abduction*

Active shoulder abduction

Category Ill: resisted break tests5

1.

Abduction.

2.

Internal rotation.

3.

External rotation.

To

be

included in the study participants were required to have: 1) pain

with of the 2 tests in category I and 2) pain with 1 test from either

category IIor category Ill.

t Subject standing.

Subject standing against a wall.

5 Subject supine with the shoulder in

30

abduction, the elbow in

90

flexion, and the forearm neutral.

jects with shoulder overuse injuriesa; and Schneider's

repor&* of increased lateral rotation of the shoulder

following joint mobilization to the cervical spine in

patients with suspected capsular contractures of the

glenohumeral joint are examples of the interdepend-

ence among joints in the shoulder girdle. The com-

plexity of joint function in the shoulder may require

treatment of shoulder impingement to extend beyond

the glenohumeral and subacromial ~ i n t s . ~ . ~ ' . ~

The purpose of our investigation was to compare

the effectiveness of 2 physical therapy treatment a p

proaches to shoulder impingement syndrome: (1) a

shoulder exercise program supervised by a physical

therapist, and (2) a shoulder exercise program su-

pervised by a physical therapist combined with man-

ual physical therapy to the upper quarter.

METHODS

Subjects

Fifty-two subjects, 30 men and 22 women, meeting

the inclusion criteria (Table

1)

were randomized into

1 of 2 treatment groups: the exercise group or the

manual therapy group (Table 2). All subjects were

referred by physicians with the diagnoses of shoulder

impingement syndrome, rotator cuff tendinitis, or

shoulder tendinitis. Subjects were subsequently care-

fully screened for the diagnosis of impingement syn-

drome according to the established inclusion criteria.

Each subject participated under informed consent of

their rights and under guarantee of full disclosure of

the benefits and risks of the study. The study re-

ceived institutional review board approval at each of

the 4 participating sites (Kaiser Permanente Fairfield,

Pleasanton, and Fremont in northern California, and

Brooke Army Medical Center at Fort Sam Houston,

Tex).

Orthop Sports Phys Ther Volurne SOeNurnber 3.March 2000


3/12

T BLE 2. Descrip tive statistics for subjects.

Manual ther py

group Exercise group

Sex

Men (n)

18 12

Women (n)

10 12

Age (years)

Mean SD

Range

Duration of symptoms (months)

Mean SD

5.6 3.7 4.4 2.8

Range

1-12 1-12

Dominant arm involved ( )

63 66

SD indicates standard deviation.

All participants were required to be between 18 and

65 years of age and to have pain with of the 2 tests

in category I (which, in combination, have been

shown to be highly sensitive for identifying impinge-

ment lesions under the coracoacromial a r ~ h * * ~ ~ ~ ~ ~ )

and pain with 1 test from either category 11% or cate-

gory 11112 (Table 1). To participate in the study, s u b

jects had to be willing to remain on current levels of

medication (initiated at least 2 weeks prior to the

study), for the duration of the study. Patients were ex-

cluded from the study if they received any other form

of medical treatment during the course of the study

that could influence the dependent variables. Addi-

tional exclusion criteria are described in Table 3.

Dependent Variables

We measured the patient's perception of shoulder

function, pain response, and isometric strength using

a functional assessment questionnaire, a visual analog

scale, and a stabilized electronic dynamometer.

The functional assessment questionnaire was devel-

oped in 1993 as a measurement tool for our pilot

study and was modeled after the Owestry Low Back

Disability Questionnaire.16 It consists of 9 distinct cat-

egories. The first category reflects the current level

of pain with general daily activity. The 6 levels of pos-

sible responses for this category range from no pain

to pain in the shoulder at all times. The remaining 8

T BLE 3. Exclusion criteria.

1. Changes in medications less than 2 weeks before or during the study.

2.

Any other form of treatment for shoulder pain during the study.

3. Pending litiga tion or workman's compensation claim.

4.

History and physical suggestive of a rotator cuf f tear or adhesive ca p

sulitis.14

5.

History of shoulder dislocation, subluxation, or fracture.

6. Cervica l radiculit is or radiculopathy.

7.

History of cervical, shoulder, or upper back surgery.

8. History of systemic or neurolog ical disease.

9.

Physical therapy or chiropractic treatment for the shoulder, neck, or

upper back in the last

12

months.

10.

Insufficient English language skills to comprehend all explanations

and respond to questions.

categories assess limitations in specific activities. Each

of these categories also contain

6

descriptive state-

ments that descend in order from no limitation at all

to inability to perform the activity (Table 4). Each

section

was

scored on a scale of 0 to

5

The scores of

all sections were summed with a maximum possible

score of 45 points representing n o limitations in the

areas assessed. In a separate reliability study, 24 s u b

jects with shoulder impairment were tested and then

retested 24 hours later. The test-retest reliability coef-

ficient for the functional assessment questionnaire

was shown to be 0.81 intraclass correlation coeffi-

cient (ICC) of (3 ,l) . The ICC was computed using

mean square values derived from a mixed model, 2-

way (trial subjects) analysis of variance (ANOVA).

Subjective pain responses were recorded for the

functional assessment activities, during resisted break

tests, and during active abduction of the shoulder us-

ing the visual analog scale, which has been shown to

be a reliable tool for measuring pain.28A l k m ine

was used for each test. The extreme limits were

marked with perpendicular lines using the verbal de-

scriptors of no pain and worst pain I can imag-

ine. The subjects were not shown their previous

markings when follow-up measurements were taken.

Measurements were expressed in millimeters.

The visual analog scale was applied to each of the

9 categories of the functional assessment question-

naire (Table 4). This measurement tool was referred

to as the functional visual analog scale. Subjects were

asked to draw a perpendicular mark on the line to

T BLE 4. Functional assessment questionnaire categories and examples of descriptive statements for the functional category of raising arm overhead.

h t q 0 r v Score Descriptive statement examples for raising a m overhead

1. Overall pain intensity

5

have no pain raising my arm overhead.

2.

Raising arm overhead

I41

can raise my arm overhead, but have mild pain.

3.

Behind the back activities

I31

can raise my arm overhead, but move slowly and carefully due to pain.

4. Reaching across body

I21

R i n prevents me from raising my arm overhead with some activities.

5 Lifting with problem arm

Ill

k i n prevents me from raising my arm overhead with most activities.

6. Lying on shoulder

101

cannot raise my arm overhead at all.

7.

Pushing and pulling

8. Carrying an object with arm at side

9. Performance of usual physical activity, sport, or

hobby

Reaching a shelf in a closet or cupboard, put ting on a T-shirt.

28

Orthop Sports PhysTher Volume3 Number 3

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2


4/12

indicate the level of pain they were currently experi-

encing in that functional category. The visual analog

scale

was

also used to rate the amount of pain expe-

rienced during resisted break tests for shoulder inter-

nal rotation, external rotation, and abduction. Here

the examiner applied manual force to slightly over-

come the subject's resistance in order to break the

muscle contraction. Each resisted break test consisted

of 1 trial test repetition (about 50% effort), followed

by maximal effort repetition. A 10-second rest sepa-

rated the 2 repetitions. Finally, the visual analog scale

was used to measure the amount of pain experi-

enced during active abduction. The sequence consist-

ed of

1

trial repetition followed by 1 test repetition.

Isometric strength for internal rotation, external

rotation, and abduction was assessed using an Accu-

force I1 electronic dynamometer (AMETEK, Largo,

Fla). Measurements were recorded in pounds (lb)

and converted to Newtons. To ensure maximal stabi-

lization, the device

was

mounted on a metal platform

that was securely bolted to the frame of the examina-

tion table. The subjects were positioned supine with

their involved shoulder in neutral flexion, extension,

and rotation with the elbow in 90 of flexion, and

neutral forearm pronation and supination. A 20

rubber wedge

was

placed with the apex in the axilla

to ensure consistent positioning of shoulder abduc-

tion. The subject's involved arm, chest, and pelvis

were stabilized on the table with belts (Figure 1).

Standardized markings from easily identifiable

bony landmarks in the forearm were used for consis

tent positioning of the dynamometer. Four hecond

isometric contractions were performed for each of

the 3 muscle groups tested; the first contraction was

a practice repetition. Each subject

was

verbally com-

manded to gradually build force to its peak within

the first 3 seconds and then continue to hold until

instructed to relax. Thirty-second rest periods were

given between contraction measurements of the

same muscle group. Two-minute rest periods were

given between contraction measurements of different

muscle groups. Interrater reliability for isometric

strength testing using this procedure was established

on 10 subjects with nonimpaired shoulders prior to

the initiation of the study. Intraclass correlation coef-

ficients (2,3) were determined: internal rotation,

0.97; external rotation, 0.94; and abduction, 0.89.

The ICC w s calculated based on a 1-way repeated-

measures ANOVA using Rater (5 levels: rater 1-5)

as

the independent variable.

Procedure

Each of the 4 research sites had 1 research team

consisting of a tester and a treater. The testers were

responsible for measurement of all dependent vari-

ables and were blinded to the group assignment for

each subject. The treaters were experienced physical

therapists who had also completed a 1-year full-time

residency in advanced orthopedic manual therapy.

They were responsible for screening, examining, and

treating the subjects.

All screening, testing, and examination procedures

were standardized and preprinted on data recording

forms. Each research team was instructed in all pro-

cedures prior to initiation of the study. The methods

used to ensure competency and uniformity included

written instruction, video presentation, and group

practice. The study

was

conducted over 6 physical

therapy sessions in a +&week period. seventh visit

was required for retesting of the isometric strength

and perceived paindependent variables. The func-

tional assessment questionnaire and the functional vi-

sual analog scale were completed a t the beginning of

treatment and again 60 days later as a means of as

sessing pain and functional status approximately 1

month after the conclusion of treatment.

Upon receiving the physical therapy referral, the

treaters screened each candidate according to the in-

clusion and exclusion criteria (Tables 1 and 3). Pa-

tients who qualified and accepted the opportunity to

participate in the study were scheduled for the initial

evaluation and testing; 2 patients declined to partici-

pate. On day 1, subjects signed the informed consent

and were appointed to either the exercise group or

the manual therapy group using the table of random

numbers. Subjects were then directed to the tester

who performed the initial measurements of all the

dependent variables. Afterwards, the subjects re-

turned to the treaters for a subjective and objective

examination of the upper quarter. The subjective ex-

amination included identifying the location, stability,

and behavior of the subject's symptoms. A detailed

history

was

obtained, and special questions such

as

the presence or change of a chronic cough, a recent

fever, multiple joint pains, or morning stiffness were

asked of each patient directed at screening for sys

temic disease and other nonmusculoskeletal prob-

lems. The physical exam consisted of active, passive,

and accessory motion testing of the shoulder, shoul-

der girdle, and cervical and thoracic spine from C2

to T6. Additional upperquarter examination proce-

dures included a segmental neurological screening,

manual muscle testing, and palpation. Following the

examination process, treatment was initiated for both

groups (Table 5).

Two months after the initiation of treatment, sub-

jects in both groups completed the functional assess-

ment questionnaire and functional visual analog

scale for the final time, and mailed them along with

the home exercise program log sheet to the research

team.

Treatment

Treatment for both groups consisted of a standard-

ized flexibility and strengthening program that was

rthop

Sports Phys Ther Volume 3 Number 3 arch 2


5/12

FIGURE 1 Isometric strength testing.

performed in the clinic under the direct one-tmne

supervision of a physical therapist. The manual ther-

apy group additionally received manual physical ther-

apy treatment directed at relevant movement limita-

tions found in the upper quarter. Both groups were

treated in the physical therapy clinic twice weekly for

3 weeks for a total of 6 visits. Both groups received 1-

hour initial examinations with an additional half

hour for testing of the dependent variables. All treat-

ment sessions for both groups were one-half hour in

length.

The flexibility program consisted of 2 passive

stretching exercises, one for the anterior shoulder

musculature and the other for the posterior shoulder

capsule and surrounding musculature (Figure 2 .

Each stretch

was

held for 30 seconds and performed

3

times with a l k c o n d rest period between each

stretch. They were performed once daily at home.

On days that they were treated in the clinic, the ex-

ercise group subjects performed their stretches in

the clinic as part of the supervised exercise program.

The manual therapy group performed their stretches

at home. This procedure w s used to equalize the

length of the treatment sessions between the

groups.

There were 6 strengthening exercises, all of which

have been recommended as the essential core exer-

cises of any shoulder rehabilitation program (Figure

3) 42 53 Four of the strengthening exercises required

the use of Theratubing (Hygenic Corporation, Ak

TABLE 5. Clinical treatment procedures.

Clinical session Procedure

Treatment visi t 1

Instructed in stretching program. Manual therapy group received manual therapy treatment and performed stretches at

home. Exercise group performed stretches in clinic.

Treatment days

2 6

Both groups received re evaluation and assessment of response to treatment.

Manual therapy group received manual therapy treatment and performed strengthening in c linic and stretching at home.

Exercise group performed stretches and strengthening exercises.

Clinic day 7

Both groups underwent posttreatment measurement of pain and strength. Both groups received instruction and com pli

ance log for home program of daily stretching and 3 times weekly strengthening.

S

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FIGURE 2. Flexibility stretches: A) stretch for anterior shoulder musculature, and B) tretch for posterior shoulder musculature.

ron, Ohio) in 6 levels of resistance. These exercises

included shoulder flexion, scaption, rowing, and hor-

izontal extensionexternal rotation. For each of the

tubing exercises, a 10-repetition maximum

was

deter-

mined. This determination was based on the examin-

er s observation of movement quality and the sub-

ject s responses with regard to fatigue and pain. De

terioration in movement quality or pain exceeding a

mild discomfort was avoided during all strengthening

exercises by either reducing the level of resistance or

modifying the ROM until the subject was able to

progress. The level of tubing resistance was adjusted

accordingly for all subjects throughout the treatment

process. Each tubing exercise

was

performed as 3

sets of 10 repetitions with a 60-second rest period be-

tween each set.

The remaining 2 exercises, the seated press-up and

the elbow push-up plus (a modification of the push-

up plus) did not require any equipment beyond a

stable chair or bench and a firm surface to lie on.J2

Both were performed to fatigue or for a maximum

of 25 repetitions. The quality of all repetitions of

each exercise was continuously monitored by the

treating physical therapist.

In addition to the standardized exercise program,

the manual therapy group also received manual ther-

apy techniques specifically applied to movement limi-

tations in the upper quarter that had been identified

as relevant to the patient s problem during the initial

examination. The manual therapy treatment

was

pri-

marily aimed at the shoulder, but may also have been

directed to the shoulder girdle, the cervical spine,

and the upper thoracic spine including the costo-

transverse articulations. In most cases, passive acces-

sory or passive physiological joint mobilization Mait-

land grades I-V were ~ s e d . ~

Initial treatment application was generally aimed at

any identified movement limitations at the glenohu-

meral joint. typical initial treatment may have in-

volved manual therapy techniques to: (1) enhance

glenohumeral caudal glide in positions of flexion or

abduction, and

(2)

increase physiological flexion or

internal rotation. Modification or progression of

treatment on subsequent visits

was

contingent on

findings in the reassessment process. For example, a

plateau in progress with treatment focused to the

glenohumeral joint would prompt the treater to: (1)

change the vigor of the technique used, (2) change

technique, or (3) direct treatment toward relevant

movement limitations in the articulations of the

shoulder girdle or axial skeleton. Typical treatment

during subsequent visits may have involved manual

J Orthop Sports Phys

Ther Volume

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Number

3 March 2


7/12

FIGURE

3. Strengthening exercises for the rotator cuff and scapula musculature:

A)

shoulder elevation,

0)

rowing,

C)

caption,

D)

horizontal extension-

external rotation, El seated press-up, and F) elbow push-up plus.

therapy techniques to: 1) improve the combined

physiological movements of hand behind back or

shoulder quadrant, 2) increase upper thoracic ex-

tension and side bend, or

3)

enhance extension, r e

tation, or side bend of the cervical spine. Techniques

also included soft tissue massage and muscle stretch-

ing particularly of the pectoralis minor, infraspinatus,

teres minor, upper trapezius, sternocleidomastoid,

and scalenes musculature. These manually applied

treatment techniques have been described in de-

taiI.'5.40All manual therapy treatments were based on

the findings of the upper quarter differential exami-

nation. Patients in the manual therapy group also

typically performed 1 or 2 additional home exercises

specifically aimed at reinforcing the effect of the

manual therapy procedures. Examples of these in-

clude simple cervical and thoracic postural exercises

such as chin tucks, and self-mobilization such as cau-

dal glides of the glenohumeral joint. The prescrip

tion of specific treatment-reinforcing home exer-

cise reflects common clinical practice for physical

therapists that treat with manual therapy.

Data Analysis

For entry into the analysis, composite scores were

created from scores on individual strength tests, from

the visual analog scale scores and from the function-

al assessment questionnaire. These composite scores

were the simple arithmetic sums of all component

scores in each category. The sample size did not jus-

tify multivariate analysis of all the dependent vari-

ables. Global improvement w s inferred from the

composite scores. Data sets were complete for all

subjects except one, for whom there were no func-

tional visual analog scale scores.

Data were analyzed descriptively and with a 2 2

mixed model M NOV and subsequent post hoc 2

J

Orthop Sports

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Ther.Volume 30.Num ber

March 2000


8/12

TABLE

6.

Results of a 2 X 2 mixed-model MANOVA and univariate ANO-

VA source table for function, pain, and strength.

Source

of

variance

f

P value

MANOVA

Group

3,45 3.02 .0393

Time

3,45 35.79


9/12

7

R beammR post

FIGURE 6. Summed scores of force measures in the manual therapy and

exercise groups before and after treatment. Means standard errors of the

mean are represented.

group). Subjects had equivalent functional assess-

ment questionnaire and visual analog scale scores in

both groups before treatment, but posttreatment

scores were significantly different between the 2

groups for these

2

scales (Figures 4 and

5).

Although

subjects in the manual therapy group had significant-

ly higher strength scores pretreatment, these subjects

significantly increased their posttreatment strength

scores by 16 while subjects in the exercise group

did not significantly improve their strength scores

(Figure 6).

DISCUSSION

In this study, supervised shoulder exercise com-

bined with manual physical therapy proved to be su-

perior to supervised shoulder exercise alone for de-

creasing pain, increasing strength, and improving

function in subjects with shoulder impingement syn-

drome. Statistically significant decreases in pain and

increases in strength were measured in the manual

therapy group after completing only

6

physical thera-

py visits over a period that varied from

21-27

days.

The statistically significant improvements in function

were measured

2

months after initiating treatment.

The changes produced in the patients receiving

manual therapy plus exercise are both statistically

and clinically relevant. Patients reported improve-

ment in the spectrum of functional activities ranging

from simple forward and overhead reaching to more

complex military and athletic activities such as per-

forming pushups, throwing a baseball, and executing

a hockey slap shot.

Therapeutic exercise has previously been deter-

mined to have long-term benefits for patients with

shoulder impingement syndr~me.~.~ased on the

significant improvement in strength in the manual

therapy group, the application of manual physical

therapy appeared to optimize conditions for per-

forming the strengthening exercises. These optimum

conditions may be due to the significant pain reduc-

tion in the manual therapy group. Subjects in the

manual therapy group were frequently observed to

have increased pain-free ROM immediately following

the application of manual therapy procedures.

Manual physical therapy might reduce pain by

stimulating oint mechanoreceptor activity, which, in

turn, is thought to block aberrant afferent pain sig-

nals and reduce the awareness of pain.59 It has also

been hypothesized that manual therapy mechanically

stretches shortened collagenous tissue and improves

interstitial fluid content resulting in restoration of

movement.52

Poor recruitment and altered timing of the shoul-

der and shoulder girdle musculature have been

shown to exist in some shoulder pain syndrome^.^^.^

The significant improvement in strength demonstrat-

TABLE 7. Descrip tive statistics for individual measures and composite dependent variables for the manual therapy group before and after treatment.

Pretreatment Posttreatment

Mean SD Mean SD

Abduction strength

External rotation strength

Internal rotation strength

Strength composite scoret

Abduction AROM pain

Resisted abduction pain

Resisted external rotation pain

Resisted internal rotation pain

Functional pain

k i n composite scoret

Functional assessment questionnairet

* Strength scores are expressed in Newtons; pain scores are expressed in millimeters (from visual analog scales); and functional assessment questionnaire

scores are expressed in points. The strength and pain composite scores were calculated

by

summing the individual measures listed above each composite

score. SD indicates standard deviation; AROM, active range of motion.

t Composite dependent variables.

134 Orthop Sports

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T BLE

8. Descriptive statistics for individual measures and composite dependent variables for the exercise group before and after treatment.;

Pretreatment Posttreatment

Mean

SD

Mean SD

Abduction strength

23 130 79

74 51 23 147 14 81 11

External rotation strength

23 99 83 40 77 23 101 88 42 06

Internal rotation strength

23 147 26 61 27 23 153 62 58 63

Strength composite xoret

23 377 88 148 28 23 402 64 162 50

Abduction AROM pain

23 50 41 22 92

23 37 54 29 01

Resisted abduction pain

23 35 27 27 77 23 32 64 29 45

Resisted external rotation pain 23 37 98 30 03

23 30 23 29 72

Resisted internal rotation pain 23 46 27 27 99 23 33 5 27 57

Functional pain

22 387 1 8 156 58 22 226 73 194 73

Pain composite scoret 22 557 1 237 20 22 360 64 272 32

Functional assessment questionnairet 23 28 52 5 47 23 33 26 7 84

Strength scores are expressed in Newtons; pain scores are expressed in millimeters from visual analog scales); and functional assessment questionnaire

scores are expressed in points. The strength and pain composite scores were calculated by summing the individual measures listed above each composite

score. SD indicates standard deviation; AROM, active range of motion.

Composite dependent variables.

ed by the manual therapy group w s clearly related

to the application of manual physical therapy in the

clinic and the manual therapy home exercises com-

bined with exercise given to both groups. The exer-

cise group did not improve significantly despite per-

forming the identical flexibility and strengthening

program. Although the manual therapy group was

stronger overall than the exercise group at the initia-

tion of the study, there w s no significant difference

in initial pain or function between the groups. De

Vriesl%as proposed that beginning strength has no

physiologic meaning, but training status will deter-

mine the potential for strength gains. He suggests

that untrained individuals gain strength at much

greater rates than individuals with an established

training program.IJ Therefore, because the exercise

group had the lowest entry strength scores, they

should have made the greatest strength gains.

Common patterns of movement limitations were

observed in most of the subjects. These patterns in-

cluded: limited shoulder flexion, abduction and in-

ternal rotation; limited accessory glenohumeral

movements directed caudally, and anterior to posteri-

or with a caudal emphasis; and limited movements of

hand behind the back and reaching across the chest.

Limitations in ipsilateral physiologic (limb motion)

and accessory (joint surface) motion were noted in

the lower cervical region and upper thoracic spine in

most subjects. Both impingement signs as described

in the inclusion criteria were found to be positive in

90% of our subjects (47/52). Pain during active

shoulder abduction was present in

96%

of our su b

jects (51/52).

The treatment procedures used in this study could

easily be incorporated into the graduated treatment

model described by Holmes et aV7 as a realistic mod-

el for delivery of services in the managed care arena.

The model emphasizes a minimal number of office

visits and focuses on patient education, home exer-

cise programs, and specific manual physical therapy

intervention.

Ideally, this study would have used a shoulder scor-

ing system with established reliability and sensitivity

to evaluate subjects. However, after carefully review-

ing the literature we found that the currently used

assessment tools were designed and best suited to

measure changes in function associated with shoul-

de r arthroplasty. At the time we initiated our study,

the reliability of these tools w s unkn~wn.~.'v~~~+'

Although our comparison study did not include a

control group, Brox et a15 has shown that exercise su-

pervised by a physical therapist is superior to placebo

and is equally as effective as surgical intervention

combined with postoperative rehabilitation in pa-

tients with primary shoulder impingement. It is im-

portant, particularly from a cost-benefit perspective,

that a small number of physical therapy visits may

produce statistically and clinically significant changes

in strength, pain, and function that are possibly

equivalent or superior to surgery.

There is the possibility the hands-on treatment

of manual therapy is perceived by the patient as

more intensive care compared to no manual treat-

ment. We tried to minimize this potentially con-

founding variable by performing the same hands-on

reevaluation of relevant objective findings at the be-

ginning and end of each treatment session for both

groups. Both groups also received direct supervision

of the strengthening program and the exercise

group performed the stretching exercises also under

direct supervision of the treating therapist. The

length of the treatment sessions w s kept equal be-

tween groups. The exercise group performed the

stretching exercises in the clinic while the manual

therapy group performed them at home to allow

time for the manual therapy treatment. In the end,

however, it is undeniable that the manual therapy

J Orthop

Sports

Phys Ther Volume SO N umber 3 March

2000


11/12

gro up received mo re hands-on time

than

the exer-

cise group received.

CONCLUSION

Manu al physical therapy comb ined with supervised

shoulder exercise is supe rior t o supervised shoulder

exercise alone fo r enha ncing strength and functi on

and reducing pain in patients wit shoulder impinge-

me nt syndrome. Our study also provides evidence

that effective outcomes are attainable after relatively

few physical therapy visits. I t s im porta nt to recog-

nize the functional interdependence o f the o ints

an d so ft tissues in the up per quarter when treating

dysfunction o f the shoulder.

ACKNOWLEDGMENTS

Special thanks to Ca rol Jo Tichenor,

MA,

PT, for

her unselfish support an d assistance thro ugho ut the

development an d evolution o f this study; Lei gh Yona-

go, MPT, for h er work in revising the functio nal

sessment questionnaire

and

assistance wi th imple-

ment atio n o f the study; L TC Steve Allison, PhD, PT

ECS, fo r per for min g the statistical analysis an d inter-

pre tin g ou r results;

Jim

Hol mes MS, PT, fo r h is statis-

tical advice and com pilat ion o f the data; the Kaiser

Hayward Or tho pedic Physical Therapy residency class

o f 1993 for their work in developing and implement-

ing the pi lo t study; and to Ly nn Mincey, MPT, Dan

Rendeiro, MPT, and Warre n Cheung, MPT, fo r their

help

in

the datagathering process.

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